Marit Bovbjerg PhD: We found that being born underwater did not confer any excess risk to the baby. Babies born underwater were no more likely than those not born in water to have a low five-minute Apgar score, or require hospitalization or neonatal intensive care (NICU) admission. We also found no evidence that waterbirth is associated with neonatal death; on the contrary, in our sample of 6,534 babies born in water, there were no cases of death that could be attributed to being born in water. This indicates that, for low-risk mothers whose labors proceed normally, water immersion is generally a safe pain management option.

For the pregnant parent, we found that waterbirth was not associated with infection or hospitalization. Surprisingly, though, we found that mothers in the waterbirth group were slightly (11%) more likely to experience perineal tearing. This finding is contrary to numerous previously-published studies, most of which reported a lower rate of tearing in mothers choosing waterbirth. The question of trauma (tearing), then, is still unresolved, and any future studies on waterbirth should make this outcome a focus.

However, even if the small, but increased risk of tearing that we reported is replicated in other studies, many individuals may still choose to labor and birth in water for the labor pain relief described in numerous other studies. For those who want to avoid epidurals and other drugs, spending a portion of active labor in a pool or tub may facilitate an unmedicated physiologic birth with all the benefits we know that confers for both mother and baby (ACNM, MANA, and NACPM, 2012; Buckley, 2014)1 Each childbearing family should weigh the potential benefits (reduction of labor pain) and the potential risks (possible increased risk of tearing), and decide based on their own values and preferences. The main upside of our research is that clients can explore these issues without worrying about whether or not waterbirth will negatively affect their babies. It won’t.

JMc: This research was based on home and birth center births from the MANA Stats dataset. Are the outcomes applicable to the hospital setting?

Melissa Cheyney PhD, CPM, LDM: As Marit just highlighted, our findings suggest that waterbirth is a reasonably safe option for use in low-risk, low-intervention births, especially when the risks associated with other forms of pharmacologic pain management, like epidural and spinal anesthesia, are considered. Because hospitals that do allow waterbirths generally only provide this option to low-risk women, we believe these results could be applied in other settings. We know that there are several hospitals here in Oregon, for example, that have active waterbirth programs and are currently tracking their outcomes. Their preliminary impressions are that babies born in water are at no greater risk, and that water immersion as a pain management strategy helps to decrease rates of epidural use.

It is possible that training and experience level of the provider makes a difference in outcomes. In our sample (based on MANA Stats) 35 percent of births occurred under water. This means that many of the midwives who contribute data to MANA Stats are very experienced at monitoring and attending births in the water. While some hospitals do offer waterbirth programs, it is currently unclear how frequently births happen under water in these facilities. One difference between the provider populations represented in our study, who are almost all CPMs and CNM/CMs, and those who might attend waterbirths in the hospital could be variability in exposure to, and experience with, labor and delivery management in the water.

That said, when we look at the balance of evidence from international studies, our study, and preliminary data from hospitals in the US, we believe that findings are converging around the sentiment that while waterbirth may not confer any particular safety benefit for babies, it almost certainly confers no added risk to the neonate in low-risk pregnancies. Families should be allowed to choose waterbirth from among a range of pain management options. We would like to see waterbirth offered more widely across the US in all birth settings.

JMc: The MANA and CfM Position Statement on Water Immersion During Labor and Birth brings together peer reviewed evidence and the clinical experience of midwives who provide waterbirth. How can childbirth educators use this document to support clients considering waterbirth?

Justine Clegg MS, LM, CPM: Because laboring and birthing in water is popular with clients, especially those choosing to birth at home and in birth centers, childbirth educators, doulas, midwives and midwifery educators need to be well versed in the issue to answer consumer questions, and provide the most current information to help families decide what is best for them.

The Position Paper is a great educational tool that gives concise access to the research and the wisdom of experience that documents the safety, benefits, and recommendations for success.

Jill Breen CPM, CLC: First, I think the research we cite will help to dispel some of the publicized concerns (drowning, cord avulsion, respiratory distress) about safety to the baby since no deaths in over 6500 waterbirths were attributable to being in the water.

The position paper also makes it clear that the experience level of the practitioner may be an important factor in the safety of waterbirth. Childbirth educators can help clients identify experienced practitioners in their area or help families develop questions that they can ask to choose a site and practitioner for their planned waterbirth.

In the position paper, Jennie Joseph LM, CPM identifies another potential outcome important to raise with some clients. Because waterbirth may reduce stress and promote physiologic birth, thereby reducing the likelihood of unnecessary procedures and disruptions of the newborn transition and parent/infant attachment, access to waterbirth may be an important tool to address disparities in outcomes for families of color.

JMc: What role should consumer choice and shared decision making play in waterbirth?

Nasima Pfaffl MA: Just as in all birth choices, shared decision making is key.

One of the primary tenants of the Midwives Model of Care is individualized counseling and education. For all birthing decisions, a midwife and the birthing family can explore the available evidence, the client’s needs, values and preferences, and the midwives experience, comfort level and clinical recommendations during shared decision making.

For example, let’s look at the conflicting findings across all waterbirth literature for vaginal tearing. The small increased risk of perineal trauma could be a deciding factor for some clients, but a small concern for those who place greater emphasis on the research findings that show overall high rates of satisfaction with waterbirth. The warmth, mobility, comfort, privacy and pain relieving attributes of laboring and birthing in water may be a deciding factor for others.

For families who want a waterbirth, I recommend when possible, choosing a practitioner with a high degree of comfort, knowledge, and experience with waterbirth. A knowledgeable practitioner will be familiar and comfortable with the differences between water and air birth (such as evaluating blood loss in water) and should be able to discuss these with their client.

JMc: How do findings from the recently released paper on waterbirth compare to the current ACOG/AAP guidelines?

Courtney Everson MA, PhD: The ACOG/AAP guidelines (Committee Opinion No. 594), released in April 2014, were a primary impetus for this study. In those guidelines, ACOG and AAP acknowledge the safety and potential benefits (i.e., pain management) of laboring in water, but also state that the safety of birthing in water has not yet been established and, thus, waterbirth is not recommended.

At the time the guidelines were written, many small- to medium-sized cohort studies from Europe were published suggesting that waterbirth was safe. However, the ACOG/AAP guidelines did not include this evidence, and cited instead primarily case series and case reports. Case series/reports are not studies; rather, they are a description of what happened to a few patients (laboring women/newborns, in this scenario). There is no comparison group and the results are based on a very small sample, which means that robust conclusions about the exposure (in this scenario, waterbirth) cannot be drawn. Knowing, for example, that one baby ended up in the NICU from the case group of 10 waterbirths is not helpful unless you also know how many babies went to the NICU from a similar group of non-waterbirths.

In the guidelines, ACOG and AAP recognize the limitations of available research, stating, “Before examining available evidence concerning immersion during childbirth, it is important to recognize limitations of studies and evidence in this area” (ACOG/AAP, 2014, 1). We believe that our research has addressed these limitations, and now offers good evidence for the safety of waterbirth.

Our sample of 6,521 women (6,534 neonates), with a comparison group of 10,252 women (10,290 neonates) who did not choose waterbirth, makes this the largest study on waterbirth to-date. Additionally, this is the first large waterbirth study in a US population, which is important because of the acknowledged uniqueness of both the US healthcare system and the US population.

With this publication, there is now a study in a US population examining neonatal and maternal outcomes for more than 6500 waterbirths. Contrary to conclusions drawn in the ACOG/AAP guidelines, findings from this study demonstrate that waterbirth confers no additional risk for babies. Future position statements and clinical guidelines should reflect the balance of evidence on waterbirth to-date, which suggests that birth in the water is a safe and viable option for low-risk pregnancies and, accordingly, should be offered as an option to childbearing families.

1ACNM, MANA, NACPM. (2012). Supporting healthy and normal physiologic childbirth: A consensus statement by the American College of Nurse-Midwives, Midwives Alliance of North America, and the National Association of Certified Professional Midwives. Journal of Midwifery & Women’s Health, 57(5), 529–532. http://doi.org/10.1111/j.1542-2011.2012.00218.x

About the authors

Marit Bovbjerg PhD, MS is a reproductive and health services epidemiologist at Oregon State University. Dr. Bovbjerg's research focuses on maternity care in the US, with a sideline into physical activity during pregnancy/postpartum. In her non-work time, she likes to knit, grow vegetables, cook, and play outside (hiking, running, biking, etc.) She does not like to sit still and in fact avoids doing so whenever possible. Marit and her husband are attempting to turn three exuberant children into responsible adults, a task at which they might, on a good day, be slowly succeeding (though likely through no fault of their own). They live in an untidy but cheerfully-painted house in rural Oregon, and enjoy vacationing in places with abundant outdoor activities but few people.

Jill Breen CPM, CLC has been serving women, babies and families for 37 years as a homebirth midwife and natural family health consultant. A MANA member since 1984, Jill has served on the Board of Directors in several positions including President, as well as on several working committees, and currently is Communications Chair. She is a founding member of Midwives of Maine, a statewide, inclusive association of midwives since 1981. Jill is a Home Birth Summit delegate active on the Collaboration Task Force. She was an appointee to the Maine Governor’s Advisory Committee on Rulemaking regarding certified midwives and was a member of the Maine CDC Inter-professional Work Group addressing flow of care across birth settings. The Maine Best Practice Recommendations for Handoff Communication During Transport from a Home or Freestanding Birth Center to a Hospital Setting was approved by the Commissioner of Health and Human Services in November, 2014. Jill writes, speaks, and mentors including as a guest lecturer at University of Maine. She is the mother of 6 children, all born at home, and has 9 grandchildren, all born into the hands of midwives, including her own.

Melissa Cheyney PhD, CPM, LDM is Associate Professor of Clinical Medical Anthropology at Oregon State University (OSU) with additional appointments in Public Health and Women’s Studies. She is also a Certified Professional Midwife in active practice, and the Chair of the Division of Research for the Midwives Alliance of North America where she directs the MANA Statistics Project. She is the author of an ethnography entitled Born at Home (2010, Wadsworth Press) along with several, peer-reviewed articles that examine the cultural beliefs and clinical outcomes associated with midwife-led birth at home. Dr. Cheyney is an award-winning teacher and was recently given Oregon State University’s prestigious Scholarship Impact Award for her work in the International Reproductive Health Laboratory and with the MANA Statistics Project. She is the mother of a daughter born at home on International Day of the Midwife in 2009.

Justine Clegg MS, LM, CPM is a Florida Licensed Midwife, Licensed Mental Health Counselor, and Certified Lactation Counselor with over 35 years experience in maternal-child healthcare, homebirth and education. She lives in Miami, FL and Asheville, NC with husband Jim Brinkman. She is currently AME Board secretary, and most recently Academic Director for Commonsense Childbirth School of Midwifery in FL. As Midwives Association of Florida “founding mother” (1979) Justine helped write and pass Florida’s midwifery licensing law, start the South Florida School of Midwifery, and was Administrative Director in the 1980s. She established a 3 year midwifery degree program at Miami Dade Community College, served as Midwifery Chair and Professor 1993-2008, and earned an Endowed Chair (2003). As Council of Licensed Midwifery Chair from 1993-2001, she helped write Florida’s midwifery practice rules. She is on Miami-Dade County Fetal and Infant Mortality Review’s team since 1997, and FIMR Chair, 2004-2008. A former Board member of MEAC and NACPM, she helped create NARM’s certification program in the 1990s. As Midwives Association of Florida CEU coordinator, she helps host MAF’s state conferences every two years. As a member of the North Carolina Midwives Alliance, Justine was MANA Region 3 conference CEU coordinator August 2011 in Cary, NC, and supports the initiative to legalize CPMs in North Carolina. She is the Midwives Alliance Documents Chair. Her 3 children and 6 grandchildren make her a “granny midwife.”

Courtney L. Everson MA, PhD is a Medical Anthropologist and the Dean of Graduate Studies at the Midwives College of Utah, Salt Lake City, UT. Dr. Everson is also the Director of Research Education for the Midwives Alliance of North America (MANA) Division of Research (DOR); Co-founder and Vice President of the Oregon Doula Association (ODA); a Research Working Group (RWG) member of the Academic Collaborative for Integrative Health (ACIH); an Accreditation Review Committee (ARC) member for the Midwifery Education Accreditation Council (MEAC); and serves on the Boards of Directors for the Australasian Professional Doula Regulatory Association (APDRA), the Oregon Doula Connection, the Association of Midwifery Educators (AME), and the Academic Collaborative for Integrative Health (ACIH). Dr. Everson's research and teaching specializations include: maternal-child health; human childbirth; adolescent pregnancy and parenting; psychosocial stress; social support; doula care; midwifery care; research and clinical ethics; evidence-informed practice; collaborative care models; mixed methodologies; health inequities; cultural competency/humility; social justice; and underserved populations. She actively publishes in academic forums, and is an invited, avid speaker at local, national and international venues.

Jeanette McCulloch BA, IBCLC has been combining strategic communications and women’s health advocacy for more than 20 years. Jeanette is a co-founder of BirthSwell, helping birth and breastfeeding organizations, professionals, and advocates use digital tools and social media strategy to improve infant and maternal health. She provides strategic communications consulting for state, national, and international birth and breastfeeding organizations. A board member of Citizens for Midwifery, she is passionate about consumers being actively involved in health care policy.

Nasima Pfaffl MA is a medical sociologist with a focus on social movements and women’s health. She is a second generation home birth mom. She is the current president of Citizens for Midwifery and has served on the board since 2006. She worked for the Midwifery Education Accreditation Council as their Accreditation Coordinator. She served on the MAMA Campaign steering committee, on the Birth Network National Board, the Coalition for Improving Maternity Services Leadership Team (Board), and as the Grassroots Advocates Committee Co-Chair and Survey Team Lead for The Birth Survey. Nasima focuses on coalition building and utilizing capacity building technologies and tools to make midwifery advocacy organizations stronger, more effective and able to create the change needed in our broken maternity care system. She lives in Florida with her son, daughters and husband. Nasima can be reached by email.

"Women should be at the heart of planning maternity services."
— Mary Renfrew, on the findings of the upcoming Lancet Special Series on Midwifery

Midwives know from lived experience the value midwifery care has for birthing families, their communities, and the world. Next week, the evidence base for the impact of midwifery care will be significantly expanded.

At the recent International Confederation of Midwives meeting in Prague, upcoming publication of the Lancet Special Series on Midwifery was announced. What is this research about and why is this release so important?

The Lancet, considered to be one of the world's leading medical journals, is devoting an entire series to bringing together all of the available information about midwifery care in one place. It comes at a critical time when policy crafters are making decisions in the U.S. and worldwide about how to fill the growing gaps in the maternal health care system.

According to the Healthy Newborn Network, the series will "Go a long way to helping make the case that investment in midwifery is a highly effective way of improving a nation's health, as well as just the right thing to do from a woman's perspective."

The series will also be multidisciplinary: ". . . It unites midwives with statisticians, epidemiologists, economists, and other disciplines," according to the Maternal Health Task Force.